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My experience of midwifery encompasses both personal and professional lives. First, like many Ugandans, I carry the ‘Maternal-Related’ experiences of my family and friends; good and tragic. Secondly, I am privileged to be among the community of practitioners and educators of midwives in Uganda. Therefore, when I was invited to speak at the International Day of the Midwife that took place at Ntare Senior Secondary School in Mbarara, Uganda, last year, I wanted to blend the stories that are familiar to me and the professional group that strives, every day, often under impossible conditions, to bring life safely into the world. Midwives shape the story of a nation. We ought to remember that!

For many of us, when we talk about maternal life, we remember not the hundreds of babies who are safely born every second around the world. We cite, by heart, the number of women and newborns who will die in the next eleven seconds (UNICEF, 2017). Or the more than eight hundred (800) who will die in a day due to pregnancy and childbirth-related complications, the majority of which are preventable. These data translate into personal stories of tragedy. This is the story of my beautiful cousin Betty. A young, vibrant, brilliant mathematician, and a beloved mother of four (2018). It is the story of my beautiful niece, and, her little one (2018); the story of my sister-in-law and her little one (2006); and also, the story of my mother and her little one (1982), all of whom did not survive complications related to childbirth. I am sure you have your own story.

The maternal tragedy is not the story of one. It is our collective story. It is the story of the poor, members of parliament, of ministers and presidents. It is the story of your sister, wife, mother, aunt, and grandmother. It is the story of a nation. And we so easily forget, that for every tragedy, there are millions of women and children who survive pregnancy and childbirth every day. I am one of them. So are you.

Midwives have always been at the heart of the nations’ maternal story and they tirelessly shape it for better or for worse. In Uganda, midwives oversee more than 2,000,000 babies who are born every year. That is more than five thousand and five hundred (5,500) babies every day. And yet, as crucial as midwives are, a gap of eight hundred and eighty-three (883) midwife positions in Health Center Twos (HC IIs) alone, exists countrywide (UNFPA, 2019). There are seven midwives per 1000 live births. This means that a single midwife oversees more than 500 deliveries a year (more than twice the 175 recommended deliveries by the WHO), often under challenging circumstances and less than ideal conditions. These data ought to keep us awake. The WHO (2013) notes that midwives are “warriors on the front-line… battling to ensure that women survive childbirth and that babies are born safely even in the most marginalized areas”. We know that access to skilled midwives/attendants mitigates child-birth related complications by up to 88% (State of the World Midwifery, 2014). That is an impressive figure. And yet, corresponding investment in their education (including in-service training); regulation & resources, practice & work-place conditions have remained largely lacking.

I often ask my students: why are you comfortable with this story? Why don’t we have enough midwives? We have and can (as a country) invest in a workforce that can effectively shape and change our maternal and child related story for the better. Why aren’t we all rushing in?

It seems to me, that beyond rhetoric, we have grown accustomed to these data. And once a year, we enjoy the scheduled reminder of why and how midwives are important. We make big speeches. We march. The media will throw in a story or two. The President may even recognize and award a midwife or several. One day is not an inconvenience. Until next year.

Frankly, this is simply not enough. And it is a bit of a puzzle. A critical gap exists between our occasional celebration of the midwife and our consistency in investment in the core areas that would significantly elevate the capacity of the midwives to continue to deliver on their outstanding promise: to bring life safely into the world.

If we want our children, sisters, wives, mothers, aunties, and grandchildren et cetera., to be featured differently in the nation's maternal and child related data, we need to rush in. A colleague recently said: that change, important change, means that we are evolving as individuals from: “thermometers who gauge the temperature of the room, to thermostats who set the temperature of the room!” Fellow Ugandan’s, here is this years’ challenge: What will you do as an individual to change and shape the story of the Midwife and the Nation? What and how will you invest?

We would like to hear about it.

Dr. Rose Clarke Nanyonga is the Vice-Chancellor at Clarke International University.

Alimah Komuhangi Oleko is a results oriented Public Health Specialist with a background in Monitoring and Evaluation, and Orthopedic Medicine. She however has a special interest in Health Education and Research, specifically targeting adolescents and vulnerable populations.

‘’Because I love what I do, I have self-driven motivation to perform my duties.’’

Her passion for teaching and community engagement shows in the effort and time she has dedicated to community work in her role as a community outreach leader at Clarke International University ,where she develops and implements new methods of teaching to reflect changes in research, and engages in new curriculum development.

We had a chat with her on her role and passion as head of Community Outreach at a high institution of learning, and why outreaches are an integral part of the education system.

Why is it important for Clarke International University to have an outreach programme?

It is an integral part of the university’s vision and mission. An Outreach Programme is a one way to enable faculty, staff and students to collaborate with external organizations in mutually valuable partnerships that are grounded in scholarship and consistent with faculty role and mission of the University.

In addition, at Clarke International University, an outreach programme is an important and valued aspect of inspiring leadership and transforming communities. It enables CIU extend its generosity and spirit of voluntarism to communities and thereby making a difference in the health sector through health promotion, health education and research.

More to that, for faculty, an outreach programme deep-rooted in scholarship enhances teaching, research, creative work and service while addressing community issues. For students, an outreach programme links school teaching and learning to community responsibility and community wellbeing. For communities, partnering with CIU increases the capacity to address important public health issues. At its best, an outreach programme offers general learning and growth opportunities to faculty, students, staff and partnering communities. The reciprocal nature of an outreach programme enriches both CIU’s academic mission and the communities we serve. In this regard, CIU has a legacy in serving the community beyond campus through an outreach programme that allows knowledge exchange and promotion of common good.

What do your outreaches comprise of? How do you carry them out?

The Outreaches comprise of;

Community Needs Assessment: where staff and students go to a specified community and identify the strengths and resources available in that community, they then provide a framework for developing and identifying services and solutions for that community.

Health Education/Health Promotion: CIU staff and students provide information that enables communities to increase control over their health using different health promotion models. Emphasis is on communicable and Non communicable diseases including life style modifications.

Medical Camps: where students provide basic treatment and general checkup to create awareness of the health status of the community. Common services provided are maternal healthcare services, Nutritional services, diagnosis and treatment of common illness, cancer screening and diagnosis and treatment of sexually transmitted diseases including Hepatitis B and HIV/AID.

Community Research Projects: Students take educational trips to refugee settlements, industries and health settings to learn outside the classroom and thereafter, they are required to develop research projects and write reports.

Scientific Conferences: Faculty and students are facilitated to attend national and international meetings and learn about recent developments, present new data to each other and discuss critical public health issues.

If we are going to partner with any external organization to carry out outreaches, we conduct a meeting with the partner and define our goal and objectives to ensure they align with those of our partners. We identify the target population. Each party clearly sets its expectations and roles in the partnership. Then we sign a memorandum of understanding. We list a set of services to offer to the community and meet several groups of people (gate keepers) of those specific communities and local leaders to introduce us to the community members. Medical camps take place at community fields, at health facilities, church grounds, school grounds and markets places depending on the target group and the leading partner. The outreach services are provided closer to where people live and are voluntary.

What kind of communities do you work with and why do you choose those particular communities?

We work with remote/rural needy communities specifically targeting the most vulnerable groups like the elderly, disabled people, people living with HIV/AIDS, pregnant women and children from disadvantaged families; normally assessed by their nutritional status. These vulnerable groups have limited or no access to healthcare services and through outreach programmes healthcare services ae brought closer to them.

We also work with communities in refuge settlements and in the urban setting we work with groups of people living in slums and urban refugees due to their highly populated nature and other unique characteristics that promote rapid spread of infection among persons. We focus on access to safe water and proper community sanitation and hygiene. All these communities have made our outreach initiative successful due to their good social acceptance behavior.

Among the communities we have worked with include; Numuwongo, Kansanga, Nakawa and the districts of Mukono, Buikwe, Mbarara, Mitooma, Koboko, and Murchison falls national park (Bulisa District). The Refugee settlements include: Bidi bidi Refugee settlement and Nakivale Refugee settlement.

What do you love most about the whole outreach initiative?

I love the passion, dedication and energy displayed by the CIU team while offering healthcare services to the community. The high volunteerism spirit displayed by the CIU team is an indicator that it’s our responsibility to contribute to the general health of a population. The Community outreach initiative enables me to instruct, assist and serve. I am able to help and connect with members of the community. The other thing I love about the whole outreach initiative is observing CIU students apply what they have learned in the “real world”. On a professional level, I am able to network. It is always great to meet like-minded individuals who share your interests. In the future, these people become important contacts when looking out for other outreach projects.

Mrs. Alimah Komuhangi Oleko during a medical camp held in Buikwe District. Emphasizing the importance of adhering to prescribed medication.

Is there anything stressful about the process? Any challenges?

The competing demands in the community such as shelter, access to food and security hamper mobilization and demean the outreach initiatives. Our primary focus is to improve the health status of the population though a one-off visit to offer healthcare services to a community may not have real impact. Sustainability can only be possible with a strong commitment at both national and local levels.

What tips or advice would you give to someone doing community outreaches when it comes to handling different people and the whole process?

Any one doing community outreaches should select a team that is compassionate, patient and with strong dedicated leadership. It is very vital for the team to have very good community knowledge and rapport with the leadership coz they influence community mobilization and participation.

In addition, it is important to know members on the planning team and a specific group or community you are trying to reach. Understand the reasons for trying to reach out to this particular group, their needs and how you intend to logistically meet the needs. Clarify activities to perform during the outreach and ensure you have a sufficient budget, source of funding to facilitate the outreach and a list of suppliers. Identify and train the volunteers and agree on communication channels.

In general;

Always conduct a needs assessment at the initial stage: This helps in efficient allocation of resources and technical efficiency. Otherwise it can be embarrassing to provide services that are not required in a community.

Set goals in relation to the mission of your institution/ organization: It is best practice to always go into the community with goal that aligns with the mission of your Organization. This helps you to get adequate organizational support and also contribute to attainment of the organizational objectives.

Know all your key stakeholders: You should know all your key stakeholders and develop a clear strategy with roles and responsibilities of all key stakeholders emphasized. Always engage the key decision makers at the planning and design stage.

Understand your target audience: For a community outreach to be effective you need to know and understand your target audience. Appropriate messages, mechanisms for outreach, and other aspects of the outreach programme depend on the nature and level of understanding of the target audience. Therefore, it is important to be culturally sensitive and respective to the target audience.

Refine outreach activities, communicate and train the team: Outreach activities have to be tailored to specific target audiences. Messages must be identified and specifically crafted to effectively convey the nature and importance of the information while simultaneously addressing the unique concerns of different stakeholder groups. All this should be communicated to the team in a timely manner and where necessary train the team.

Get feedback from the community: Getting feedback from the community enables the team to actively take out time to analyze positive criticism, and then thinking of the best possible solution to perform better. It provides and allows team members to see what each one can change to improve their focus and results.

Mrs. Alimah Komuhangi Oleko during an Institutional training to build leadership capacity of employees at Refuge and Hope International- Uganda.

Any future plans for community outreaches at CIU?

We plan to scale up medical camp initiatives to other communities. This is based on the demand from these communities. Individuals read about what we do and invite us to offer healthcare services. Rakai district is among the target communities for this year and we are also considering Bundibugyo and Kasese districts in the near future. We want to conduct an extensive community needs assessment in these communities so as to offer healthcare services tailored to their health needs.

Secondly, to establish and strengthen community disease surveillance systems. We intend to achieve this by training community health workers to build their capacity in identification, early detection and reporting of cases for specified health conditions to inform the health management information system.

Thirdly, we plan to conduct impact studies in the communities of Namuwongo, Kansanga and Mitooma where we have been carrying out annual medical camps. This will be done through focus group discussions/ round table discussions with key partners in these communities. In addition, creation of a peer review- scientific journal is ongoing to play a role in disseminating outreach findings. This will increase our involvement in influencing public policy.

Last but not least, we are engaged in continuous efforts to identify key stakeholder groups and find opportunities to enhance our community engagement.

What do you hope to teach/show/share with the world with this initiative?

I want the world to embrace community outreaches as a way of showing love, care and compassion to the vulnerable communities. Communities are very important and are at the center in healthcare programming at local, national and international level. If the health of a smaller community is jeopardized, we are likely to witness a lot of disease spread which is an indicator of a poor health care system in any country. I hope that with our outreach initiative, communities shall be able to understand how best to prevent and manage their health conditions and how to demand for healthcare service provision from concerned authorities. In addition, I hope that the initiative influences students at CIU to give back to the community and to maintain the same spirit even as alumni in order to enable our communities grow substantially.